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When bmCompleteO. <br /> .;.,,r. •w:,:;--rte •�._.--... <br /> t <br /> Applications Wilt Be Processed SuAPf1PL� ATION <br /> (For Non•Transla6ble,Revocable,arid Suspendable} SEPTAGE <br /> ENVIRONMENTAL HEALTH PER • <br /> LIQUID WASTE <br /> gpplicat on is hereby et car 6usl aln the stlic'onalgadd essthe San Joa uin local alth Cisinc <br /> " �* o <br /> a Business jqame (DBA) Address ) <br /> z Owner C �I <br /> Firm Partners,Addresses and Telephone Numbers Emergency Telephone NO. <br /> a Busfneas Telephone No- Date <br /> Till <br /> Contractor Licence No. <br /> I-Applicants Name(Print) <br /> he� <br /> Please check Applicable Category(1-7)and Fill In tRegwrod Information <br /> b . <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH YEHICLE). ; <br /> For July 1, June 30,19 L , <br /> Oisposal'Sites �•tia t ' <br /> CAL.LlCensB Renawal,Na. <br /> I '6dscriptlon(MRI a Yr•,C"r) - --CAL.License No. <br /> j Serial No. Weights&Measures NO. <br /> Capacity <br /> Equipment Parking Address - <br /> f 2. ❑ WMPER YARD <br /> If For July 1, <br /> June 30.19 <br /> 4ttl No.of Vehicles Stored I <br /> No.of Chemical Toilets Stored :` R.S.or R.C.E.No. <br /> g, 'Q PERCOLATION TEST <br /> R.S.or R.C.E.Name ---------- I Test Date/Tirne <br /> / I •+ <br /> j Test 1,008tion I rn <br /> S+ p,• l, SANITATIONPERMIT •Q • If <br /> 1. <br /> job Add ss/Lo Etion _ ! .Address p PACKAGE PLANT ,p <br /> ){ Owner 0LEACHING FIELD ❑ SEEPAGE PIT OTHER <br /> Ll SEPTIC T [] CESSPOOL <br /> ANK 'NEW El REPAIR y GI <br /> ❑ PERMANENT' 13 TEMPORARY <br /> 5, 0 CHEMICAL TOILETS For July 1,-June 30.1Disposal Site .K <br /> Type Construction Equipment Storage/Cleaning Locatlon(s) <br /> i <br /> No.of Units A <br /> fi <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1,-June 30.19 Where Ce�i <br /> ( Operator Name <br /> Plant Location No.Units Served <br /> tk plant Capacity <br /> 1 7. 13 LAUNDRY For July 1,-June 30"119�ore?haO 1,000 Sq.Ft <br /> SIZE: , <br /> . L} Less Than 1,OD0 Sq.Ft., <br /> I7 DRY CLEANING,Chemicals Used/Amount/100, <br /> r,{I i. .•,+•,� Joaquin County <br /> •�- 1 <br /> cert{ that 1 have prep red'.thls application and that the work will be done 1,!accordance with San <br /> Phereby ry i <br /> ordinances,state Is .a d rules entl,r lotions of the San Joaquin Local Health District <br /> f i 4 <br /> NT <br /> APptS 3I <br /> ` ' GNATUREX r <br /> t 1 <br /> FOR DEPARTMENT USE ONLY j, <br /> I t a Rat ' ,aY Janunry at Q July 1&ReCBFetl 9Y JULY 31 <br /> f 1 ❑ January i REMIT <br /> $ AMOUNT DUE CHECKED <br /> Fea,IS Due;13 ANNUALLY PIPER UNIT i ❑'PER SITE EACH REMITTA CE REMITTED <br /> AMOUNT <br /> 'BILLING ,DA <br /> BASE E%PIA,;ATION I DATE <br /> FEE ' S.a•+8' , "•,t.w.- —. <br /> sm <br /> p 4 ' <br /> ' flORATIDNPLUS <br /> t :� <br /> FPENALTY 1 <br /> OTHER <br /> { q - <br /> OTHER FiM1'I ' <br /> Ye7� -- w�� at MailedDan oae <br /> etelveabyr Or rmit No. teat El HAZELTONAVF..P.O'9oL'Na,Y.`.9TOTON,GA 95101 <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIAONNENTAL NEALTRP RMITISERYICee <br /> ' <br />